Swamped ERs turn away ambulances

Monday

Mar 31, 2008 at 12:01 AMMar 31, 2008 at 12:38 PM

Hospitals sometimes are forced to turn away ambulances dozens of times a year because their emergency rooms are packed and they have too few beds to spare, but most say they are fighting to reverse that trend.

David Riley

Hospitals sometimes are forced to turn away ambulances dozens of times a year because their emergency rooms are packed and they have too few beds to spare, but most say they are fighting to reverse that trend.

Diversions have become more common in the past decade not only in Massachusetts, but nationwide. The causes are complex, but emergency rooms are seeing more uninsured patients seeking basic care, and aging baby boomers needing more medical attention. And all this comes years after many hospitals have merged or cut beds to make ends meet, hospital officials say.

Many hospital have been working in recent years to become more efficient, from the waiting room to discharging patients, to reduce the number of times they have to make the painful decision to turn an ambulance away.

"It's day in and day out," said Cheryl Bonasoro, vice president of patient services at Milford Regional Medical Center. "It's our bread and butter."

That's welcome news to emergency responders who say they sometimes have to drive farther to find treatment for patients who are used to getting treated at their local hospital.

"It takes our ambulance that much farther out of town," Ashland Fire Lt. Keith Robie said of diversions. "You can clear Framingham and get back to Ashland pretty quick, but when you're on the other side of Milford, it's hard to race back."

A hospital on diversion closes its doors to ambulances in all but very serious cases. Hospitals use a Web site to notify emergency responders. Walk-in patients are still seen and treated.

This can happen when an emergency department sees an influx of patients and is struggling to keep up, said Candra Szymanski, chief operating officer at Marlborough Hospital. But more often, the hospital diverts when in-patient beds are full and staff has no room to admit new patients, she said.

"Historically, having been an emergency department nurse ... I never like to divert," Szymanski said. "But there are times when you have no choice."

Marlborough Hospital went on diversion 800 hours last year, according to state Department of Public Health statistics. That was a major spike from 204 hours in 2006.

The increase was caused partly by badly needed renovations in a building constructed in 1965, Szymanski said. That made fewer beds available. Renovations should wrap up in the next few weeks, she said, but the causes of emergency room crowding remain nationwide.

"More and more people are starting to use an emergency department for their primary care," Szymanski said. That's sometimes because patients feel they can't wait to see their regular doctor, or they just don't have primary care physicians, and there are fewer and fewer of them today.

ER visits increased twice as fast as the U.S. population from 1993 to 2003, from 90.3 million visits to nearly 114 million, according to a 2005 report by the U.S. Centers for Disease Control.

Hospitals also cut beds in the past, Szymanski said. The closure of Waltham Hospital in 2003 sent more patients packing into Newton-Wellesley Hospital, for example.

"Now you have an aging population, you have a shortage of nurses, and now we find that many of us don't have the beds to be able to handle the population we serve," she said.

"None of us make this decision lightly," she said of diversions. "We all know the impact."

At MetroWest Medical Center, which includes Framingham Union Hospital and Leonard Morse Hospital in Natick, CEO Andrei Soran said he has made it a priority to reduce diversions since arriving in 2005.

That work seems to be paying off. Diversions there peaked in 2004 and 2005, according to state Department of Public Health figures. Framingham Union Hospital had to turn away ambulances for a total 493 hours in 2004.

But last year, the Framingham hospital had whittled diversions down to 139 hours, with fewer at Leonard Morse. And most times, if one hospital is turning away ambulances, the other remains open, Soran said.

"I think we improved the processes in-house, inside the hospital, to allow this to happen less often," he said last week. "We are proactive in limiting the amount of times we go on diversion. It's an impediment to the community and also it's disturbing the business as well."

The ER at Framingham expanded in 2005. Soran said the hospital now has a prediversion process that calls "all hands on deck" to help process patients when the emergency department is stretched.

"Everybody has to pitch in and help with the flow," said Soran, who also has to be called now before the hospital can go on diversion.

The hospital also tries to make sure patients are discharged smoothly, with family ready to pick them up and doctors writing discharge orders in a timely manner.

Still, diversion is sometimes necessary.

"It's more dangerous to direct an ambulance to a place that's overcrowded and people are stretched to the limit of their professional capabilities," Soran said. "At some point in time, you have to pull that trigger."

Soran said he supports the state's new health care law that requires people to buy insurance.

"The more people have insurance and can get preventive care or basic primary care, the less burden you're going to have on the emergency rooms," he said.

At Milford Regional Medical Center, diversions are extremely rare - at the most since 2002, the hospital only diverted for 19 hours in 2002, and fewer than five hours each of the last four years.

That's partly because of the hospital's isolated location - it's about a half-hour from any other acute care facility, said Maria DaSilva, director of emergency services.

"I think for us because it's 30 minutes away, it's a much tougher decision to make and we do everything to avoid it," she said.

While the Milford hospital faces many of the same challenges - it sees an 8- to 10-percent jump in the number of patients each year, Bonasoro said - its staff also has plans in place to avoid diversions. That includes at least daily meetings about which patients might be sent home to open up available beds. When the ER has a backlog, a team meets to discuss how to clear it up.

The hospital also has administrative and staff committees dedicated to making the emergency department more efficient, Bonasoro said.

At the same time, the hospital is careful not to discharge patients too early to open up beds, she said - that can mean a patient returns to the emergency room within the day because they were sent home too early.

While hospitals have made some headway, state legislators have discussed banning diversions, Bonasoro said, and pressures on hospitals continue to increase.